Provider Demographics
NPI:1467692244
Name:77TH ST-5TH AVE MEDICAL, P.C.
Entity Type:Organization
Organization Name:77TH ST-5TH AVE MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIOT
Authorized Official - Middle Name:H
Authorized Official - Last Name:ZIMBALIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-921-5548
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-0086
Mailing Address - Country:US
Mailing Address - Phone:516-697-6813
Mailing Address - Fax:
Practice Address - Street 1:452 77TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3256
Practice Address - Country:US
Practice Address - Phone:718-921-5548
Practice Address - Fax:718-921-5781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149213207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty